Ryan Marotta, Associate Editor

The growing cost of prescription medications continues to be a source of concern for lawmakers, patients, and providers, yet pharmacists can play a crucial role in ensuring that patients have access to the treatment they need.

, Republicans, and the Trump administration are all taking aim at the rising cost of medications, but solving the issue of high drug prices first requires an understanding of why costs are rising, according to Kathy Chase, the director of drug cost control services for Cardinal Health. 

“There are many reasons for rising drug costs,” she said in an interview.

“A couple of the key ones we see are the development and release of a lot of the newer specialty biologicals that focused on cancer care or rheumatoid disease. In addition, as the availability of certain drugs decreases, the costs of these drugs go up exponentially," Chase said.

John Kilgour, the vice president of acute and alternate care sales for specialty pharmaceutical distribution at Cardinal Health, added that the costs tend to be higher for the increasing number of drugs aimed at treating smaller disease states.

“I think that what we all see today in health care is that there are rising numbers of small disease state patient bases and for each of those different and smaller entities there are unique drugs being made all the time to address those very specific things,” her said. “The cost associated with introducing those are very pronounced, and being able to get your hands on a particular product when you need it for that patient is just critical today.”

A final factor in rising drug costs cited by Chase is the growing use of personalized medicine, which can come with a hefty price tag.

In 2018 alone, there were a record number of 25 personalized medicines approved, accounting for 42% of all 2018 drug approvals, according to the recently published report from the Personalized Medicine Coalition, the "

Personalized Medicine at FDA: A Progress & Outlook Report

“The last thing I would add is that we also see a lot of more personalized medicine that you didn’t see even 5 years ago. We can take your cancer and look at the gene profile for that type of cancer and have a very customized drug therapy,” Chase said.

“Those custom, specialized drugs are what really become expensive," she said.

When asked about the implications of rising drug costs, Chase expressed concern about how high prices affect patient access and adherence.

“Access of the drugs for the patient can certainly be affected by prices,” she said.

“The drugs can be expensive; do these patients have insurance? Can they afford to pay for them? Are they available to their doctor or their community hospital?" Chase asked.

"So, the biggest impact to the patient becomes whether they can get a hold of those particular drugs," she said.

Both Chase and Kilgour noted that  pharmacists can play a key role in facilitating patient access to expensive medications.

In addition to making sure that the patient has access to programs that may help supplement payments for their more expensive medications, "pharmacists can always look at what’s going on, look at their data, and remain aware of what they’re buying and what the trends are,” Chase said. 

“Keeping the patient first in mind is key, it’s why we all do this, &#8203;&#8203;&#8203;&#8203;&#8203;but getting back to the basics, running the operation, and making sure you manage against obsolescence are all important. ” Kilgour said.

"Some of those drugs in the specialty segment are very expensive. You can’t afford to have those drugs go out of date," Kilgour said.

“I think that’s where we worked with hospitals to bring tools that can help hospitals manage their inventories, as well as tools to help them identify the diseases that someone might want to use a drug for,” Chase said.

“All of the data you have available to help you make those decisions is crucial," she said. "So, for pharmacists, partnering with physicians and other providers can help to manage costs.”

Ultimately, as health care evolves and technology advances, innovation will prove essential for tackling complex problems, such as drug pricing, Kilgour said.

“You have to be very mindful of your pharmacy operations, make sure that you’re optimizing the inventory you have on hand, and look at technology to see if there are things that you can do creatively and innovatively that maybe haven’t been done before," he said.

Articles

High prices can negatively affect patient access and adherence.
 

Rising Drug Costs: What Are the Contributing Factors?

Although many pharmacists are divided when it comes to their job satisfaction, most of them are happy with their compensation, according to a recent 

 in this 3-part series provided a general overview of the survey and its respondents. In this article, we will explore the questions and answers concerning compensation.

When asked on a scale of 1 to 7 (with 1 being "not at all" and 7 being "extremely") how satisfied they are with their current annual total compensation, about 62% of 290 pharmacists gave a favorable answer of 5, 6, or 7. Comparatively, about 24% of respondents gave a more lukewarm answer of 3 or 4, while about 14% rated their salary satisfaction as 1 or 2. For a breakdown of how pharmacists responded to this question, please see the 

Many respondents also seemed to suggest that they had grown slightly more satisfied with their salary since graduating from pharmacy school. When asked to rate (from 1 to 7) how satisfied they were with their annual total compensation during their first year after pharmacy school, about 60% of 290 respondents gave a favorable score of 5, 6, or 7, while about 28% gave a score of 3 or 4 and 12% gave a score of 1 or 2.

Additionally, about 48% of respondents indicated that they had received some form of additional compensation, such as bonuses or profit sharing, in the past year. Comparatively, just 35% of respondents had received additional compensation during their first year after graduating pharmacy school.

Notably, the survey results showed a shift from community pharmacy practice to health systems and other nontraditional settings during the course of some pharmacists’ careers. When asked about the practice setting in which they primarily worked during their first year after graduating from pharmacy school, 64% of respondents answered that they worked in a community pharmacy, 26% said that they worked in a health-system pharmacy, and 9% described their primary setting as “other.” However, 52% of pharmacists indicated that their current primary setting is a community pharmacy, while 31% of pharmacists said that they currently work in a health system, and 16% described their current primary practice setting as “other.”

Although the majority of survey respondents were generally satisfied with their salaries, some were more critical. Katherine Cheng, PharmD, a New York state community pharmacist with 17 years of experience in the profession, rated her satisfaction with her annual total compensation as a “3.” Specifically, she voiced concern about the fact that the evolving roles and responsibilities of pharmacists are quickly outgrowing both salary levels and regulations meant to protect pharmacists and the patients they serve.

“Although we are paid a decent salary, I do not feel we are fairly compensated as long as laws governing our well-being are lacking. For example, many retail pharmacists continue to work 8-hour or more shifts and are not provided a break,” Cheng said in an interview.

“The workload, especially with emerging roles of a pharmacist, make it unrealistic for us to take a few minutes for ourselves,” she said. “While I am an advocate for the expansion of the pharmacist's role in health care, I am against the high workload demanded of us without sufficient support staff which has been shown to lead to higher rates of medication incidents.”

Cheng also said that current salary levels are not adequately keeping pace with inflation and tuition rates, placing an excessive burden on the growing number of recent pharmacy school graduates.

“It's sad to see that starting salary for a new pharmacist is equal to or perhaps even lower than what it was 18 years ago, when factoring in rise in cost of living and inflation,” she said. “Pharmacy students are spending more time in obtaining their degree but aren't being compensated for the additional education, due to too much competition from the overabundance of graduates.”

However, Cheng ultimately emphasized that salary was not as important to her as other factors.

“More than monetary compensation, I would personally like to see a healthier, more humane work environment,” she said. “Monetary compensation means little when you don't have your health or sanity.”

Pharmacists are Happy With Their Salaries, Less So With Their Jobs, Survey Shows

, we will explore how survey respondents view their job satisfaction.

Although many pharmacists are divided when it comes to their job satisfaction, most of them are currently happy with their compensation, according to a recent Pharmacy Times® Salary and Job Satisfaction Survey.

Pharmacists Are Happy With Their Salaries, Less So With Their Jobs, Survey Shows (Part 2)

A prescription drug commercial that aired during the broadcast of 

has set the stage for a larger conversation about patient access to preexposure prophylaxis (PrEP) medication.

The advertisement was for Gilead Sciences’ emtricitabine and tenofovir disoproxil fumarate (Truvada), the only FDA-approved PrEP drug available for the prevention of HIV.

Daily use of Truvada has been estimated to reduce HIV infection in at-risk individuals by up to 92%, according to the CDC.

Gilead’s decision to advertise Truvada during 

was fitting, as the musical, a loose adaption of the opera 

 set in New York City against the backdrop of the 1990s HIV/AIDS epidemic, prominently features several characters with AIDS and highlights their struggles with the disease.

This connection did not go unnoticed by viewers, who took to social media to share their thoughts on the commercial. Many praised Gilead for raising awareness of PrEP among a national audience, and some celebrated the ad’s placement during the 

 broadcast as a symbolic milestone in the fight against HIV and AIDS.

 commercial on NATIONAL TV. On a MAJOR NETWORK. On prime time. During 

 and reaching an audience that needed to see it. I'm crying. And never more proud to be prescribing HIV Prevention. 

Other reactions, however, were more critical. In particular, some viewers expressed frustration with what they said to be the high cost of Truvada. They said this cost may keep the drug out of reach for many patients who could benefit from it. Additionally, HIV/AIDS advocacy groups, such as ACT UP, called on Gilead to “break the patent” and allow a more affordable generic version of Truvada to come to market.

Although the FDA granted approval to a generic formulation of Truvada in June 2017, Gilead indicated in a statement that its patent on 1 of the drug’s components, emtricitabine, would not expire until 2021. Its patent on the other component, tenofovir disoproxil fumarate, expired in July 2017.

As dialogue surrounding the price of Truvada continues, pharmacists can play a crucial role in educating patients about the importance of PrEP and removing barriers to its access. Notably, the results of a recent study conducted by researchers from the University of New Mexico suggested that pharmacist-led programs that provide PrEP to high-risk populations can help lower HIV infection rates.

Pharmacists can also point patients who were prescribed Truvada to financial assistance resources at 

truvada.com/how-to-get-truvada-for-prep/truvada-cost

. Updated November 1, 2018. Accessed January 28, 2019.

Ryan B. FDA approves generic Truvada for HIV Treatment and PrEP. 

poz.com/article/fda-approves-generic-truvada

Keenan R, Lewis J, Sanchez D, Anderson B, Mercier RC. The next step in PrEP: evaluating outcomes of a pharmacist-run HIV pre-exposure prophylaxis (PrEP) clinic. 

idsa.confex.com/idsa/2018/webprogram/Paper72194.html

A prescription drug ad broadcast during the musical on television has set the stage for a larger conversation about patient access to preexposure prophylaxis medication.

Truvada Commercial During 'Rent: Live' Sparks Dialogue About PrEP Accessibility

Institute for Safe Medication Practices (ISMP) releases its review of the year's most common medication safety issues.

During a session at the 2018 American Society of Health System Pharmacists (ASHP) Midyear Clinical Meeting, ISMP medication safety specialist Christina Michalek, RPh, gave an overview of the most common medication errors reported to the organization in 2018 and discussed effective strategies to best mitigate harm. 

Safety issues highlighted by Michalek during the sessions included:

Michalek described an incident in which a patient with a documented penicillin allergy was prescribed amoxicillin clavulanate. Alerts notifying the pharmacy team to the allergy was bypassed, and the medication was dispensed, leading to the patient experiencing difficulty breathing.

Alerts like this one are sometimes overridden when it is unsafe to do so, Michalek said.

Potential solutions to this issue include improvements in alerting mechanisms and allergy documentation, as well as continuous alert monitoring and more thorough patient engagement.

In the past year, several errors and hazards related to investigational drugs have been reported to ISMP. Many of these events were related to labeling, nomenclature, and packaging.

Regulatory guidance for investigational drug labeling, is limited, Michalek said.

However, both the ASHP and the Hematology/Oncology Pharmacy Association have developed their own sets of guidelines for investigational medication, while the Joint Commission has required safe management for the review, approval, supervision, monitoring, storage, and labeling of these drugs.

According to Michalek, safety issues with drug labels and packaging reported in 2018 involved:

Inadequate prominence of reminders and warnings

Inconsistent and unclear expressions of strength

Given the various problems associated with inconsistent labeling practices, the FDA and International Safety Network have spearheaded international efforts to improve medication safety by standardizing design elements, labeling, and packaging. Additionally, the ISMP has recommended that the FDA develop guidance on standard labeling.

There are a number of contributing factors associated with vaccine errors, including knowledge-related factors (incomplete vaccination history, unfamiliarity with the product), practice-related factors (failure to verify patient information, miscommunication of order or due date), and product-related factors (age-dependent formulations of the same vaccine, similarly labeled or named vaccines), according to data from the ISMP's National Vaccines Error Reporting Program.

To avoid future errors, the ISMP recommends that providers document all information, educate both patients and staff members, establish or examine protocols, optimize vaccine storage, review how vaccines are listed, and verify immunization status.

Acknowledging that further work is needed to improve medication safety in these and other areas, Michalek ultimately emphasized the importance of aligning process and policy with data.

“Medication safety will always be evolving work,” she said. “As new knowledge emerges, we need to dedicate effort towards improving current state processes.”

Michalek C. ISMP’s top medication safety issues during 2018. Presented at: 2018 ASHP Midyear Clinical Meeting. December 2-6, 2018. Anaheim, California.

Each year, the Institute for Safe Medication Practices (ISMP) releases its review of the year's most common medication safety issues.

ISMP Highlights Top Medication Safety Issues in 2018

Given their crucial role in promoting and ensuring medication safety, pharmacists must remain educated about common medication errors and ways to prevent them, according to the Institute for Safe Medication Practices (ISMP).

During a session at the 2018 American Society of Health System Pharmacists (ASHP) Midyear Clinical Meeting, ISMP medication safety specialist Christina Michalek, RPh, presented the organizations’ annual review of the year’s biggest medication safety issues.

Pharmacists must remain educated about errors and ways to prevent them, according to the Institute for Safe Medication Practices.

ISMP Explores Top Medication Safety Issues of 2018

As technological innovations continue to transform health care, many pharmacists and other providers are increasingly looking to digital solutions for improving medication adherence among their patients.

American Society of Health-Systems Pharmacists (ASHP) Midyear Clinical Meeting, 

Timothy Aungst, PharmD, an associate professor at the MCPHS University School of Pharmacy and contributing writer for 

 discussed the approaches taken to increase adherence in the smart phone era. Acknowledging the multifactorial nature of nonadherence, Dr. Aungst noted that low-tech devices—including digital timer caps, and simple pillboxes&mdash;failed to yield significant improvements in clinical trials.

Given the ubiquity of smart phones, tech companies have created a variety of digital devices and platforms aimed at boosting adherence. Several of those highlighted by Dr. Aungst in his session include:

Serving as a “digital medical hub” for user, mobile apps alert patients when to take their medications while allowing them to record their history. The major draw of these apps is their cost-effectiveness: most apps are free, though some will collect data for resale. Many apps also encourage adherence through the use of gamification and metrics.

However, most apps are standalone software, and have little integration into a larger platform. Additionally, patients who mark that the app’s alerts may not have necessarily taken their medication, making it difficult to track absolute adherence.

Although there is little literature on the effectiveness of medical apps in improving adherence, one study found a small improvement in self-blood pressure monitoring among patients with hypertension who used an app.

 These devices can track when patients take their medications through sensors in a cap that detect when a bottle is open, or through sensors in the bottle itself that determine the weight of the remaining pills. Smart bottles can be used without an app or other technology, and they can be added to a patient’s preexisting framework.

For patients who take multiple medications, however, the cost of theses bottles can quickly add up, and although these device can track when a pill is removed, they cannot track whether the medication was taken.

In one study, researchers noted an increase in self-reported adherence among patients who used smart pill bottles but no comparable change in therapeutic levels.

High-tech versions of blister and strip packaging, smart package devices serve as reminders for patients and provide tracking of dispensed doses. Smart package systems are particularly useful for patients with multiple medications, and they can integrate with drugs packaged by a pharmacy.

Because smart package systems are larger, they can be very expensive, but they have the potential to serve as a “one-stop” device. As with smart pill bottles, they can only track if a pill was removed, not if it was taken.

A study in which patients were given smart pill trays and counseled by a health coach found increased adherence levels among these patients but no difference in drug concentration; furthermore, it remained unclear whether the boost in adherence was due to the devices’ use or to the health coach’s involvement.

Playfully described by Dr. Aungst as the offspring of the above technology and Amazon’s Alexa, these device incorporate home voice assistants, remote access to health care professionals, and other activation features while dispensing medication.

As with smart package systems, smart pill dispensers can be very expensive, but likewise can meet a variety of patient needs. These devices also face the same difficulty in tracking absolute adherence.

These devices are embedded onto an oral drug that, when dissolved, sends an alert to a patient’s smart phone and later physician via a wearable patch indicating that the patient has taken his or her medication. The first FDA-approved drug with a bioingestible sensor, Abilify Mycate, received the agency’s nod in November 2017.

Although bioingestible sensors can track adherence, they do not themselves improve adherence. Given the novelty of these devices, their average cost to consumers remains uncertain.

Dr. Aungst suggested that digital technology could prove a key tool in improving medication adherence and collecting objective, real-time data, though he emphasized that much more work and innovation is needed to make that potential a reality.

“Digital health presents a novel means of assessing and potentially improving medication adherence through multiple interventions,” he concluded. “However, a current focus on an ‘all-in-one’ solution platform has not led to promising clinical results at this time.”

Aungst T. From Pillboxes to Smart Pills: How Digital Health is Changing Medication Adherence. Presented at: 2018 ASHP Midyear Clinical Meeting. December 2-6, 2018. Anaheim, California.